Results 1 to 3 of 3

fraudulent coding

  1. #1
    Default fraudulent coding
    Medical Coding Books
    Hi,
    I am needing some info to give to my superior's on the description of fraudulent coding.
    scenario: I coded out a claim for an laparoscopic unlisted procedure, the insurance changed the code on the EOB and wanted us to accept payment for a open similar procedure (which we did not). My superior said why can't we I said it is fraud and she says where is there info supporting this. Can someone direct me to info supporting my ethics so that I can show them concrete info? Besides I say so!!
    Thanks

  2. #2
    Location
    Columbia, MO
    Posts
    12,913
    Default
    Quote Originally Posted by gterri View Post
    Hi,
    I am needing some info to give to my superior's on the description of fraudulent coding.
    scenario: I coded out a claim for an laparoscopic unlisted procedure, the insurance changed the code on the EOB and wanted us to accept payment for a open similar procedure (which we did not). My superior said why can't we I said it is fraud and she says where is there info supporting this. Can someone direct me to info supporting my ethics so that I can show them concrete info? Besides I say so!!
    Thanks
    Am not certain you are correct that this is fraud, normally when you use an unlisted code you make a not in field 19 with the compare to code and you set you fee to be somewhat close to that procedure. Without any further information, this may be exactly what the payer did. I am curious as to why you think it is fraud.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Dover Seacoast New Hampshire
    Posts
    2,028
    Default
    Unlisted procedures are subject to payer discretion. What did you expect to receive for payment on an unlisted code? There would be no fee schedule, and there are no guidelines in CPT with regards to an unlisted code, which is why you enter in Box 19 as Debra mentioned your understanding of the most appropriate best guess. They paid you based on what they felt was the appropriate code because you didn't indicate a comparitive code. They didn't commit fraud; but you also didn't submit a clean claim.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

Similar Threads

  1. Fraudulent Billing
    By BABS37 in forum Billing/Reimbursement
    Replies: 8
    Last Post: 05-31-2014, 07:00 AM
  2. Fraudulent Bill?
    By anlagrange in forum Billing/Reimbursement
    Replies: 2
    Last Post: 11-03-2011, 07:56 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.